Haematuria and bladder cancer (module 1)

Question 1

visible haematuria may be referred to as

Answer 1

frank or macroscopic haematuria

Question 2

non-visible heamaturia may be referred to as

Answer 2

microscopic haematuria

Question 3

non-visible blood in urine is detected by

Answer 3

microscopy or dipstick urinalysis
3 red blood cells per high power microscopic field indicates microscopic haematuria

Question 4

most common cause of frank haematuria in adults >50

Answer 4

bladder cancer
15-22% of pts with macroscopic haematuria have cancer in the urinary tract
5% of pts with microscopic haematuria have cancer in the urinary tract

Question 5

haematuria with concurrent UTI

Answer 5

do not rule out bladder cancer just because a UTI is present.
bladder cancer is often associated with infected urine.

Question 6

does the presence of visible blood indicate more serious pathology than non-visible blood

Answer 6

yes
visible blood increases risk of more serious pathology

Question 7

heamaturia with pain may indicate:

Answer 7

Dysuria or irritative lower urinary tract symptoms may indicate cystitis
Severe abdominal or pelvic pain may suggest ureteric (or bladder) calculus

Question 8

haematuria with blood clots

Answer 8

indicates high degree of haematuria and often means significant urological pathology and may need catheter and bladder washout

Question 9

DDx for haematuria

Answer 9

• carcinoma (bladder, kidney, ureter, prostate)
• infection
• stone
• trauma eg. catheterisation
• renal eg. glomerular disease, polycystic kidney
• benign prostatic hyperplasia
• anticoagulation
• papillary necrosis
• bleeding disorders eg. haemophilia, sickle cell disease

Question 10

what to look for O/E

Answer 10

Palpable masses
pain (stones)
rectal exam - revealing enlarged prostate (hard and heterogenous may reveal prostate cancer)
weight loss
anaemia
signs of chronic renal failure

Question 11

essential investigations for haematuria

Answer 11

• cystoscopy
• upper tract investigation (USS +/- IVU or CT urogram)
• urine microscopy culture and sensitivity
• urine cytology (selectively)

Question 12

more than 90% of bladder cancers are

Answer 12

transitional cell carcinomas
a few of the rest are squamous call carcinomas or adenocarcinomas

Question 13

male to female ratio of bladder cancer is

Answer 13

male : female
2.5 : 1

Question 14

risk factors for bladder cancer

Answer 14

age
male sex
smoking
family history
workers in industries exposed to carcinogens

Question 15

risk factors for bladder cancer

Answer 15

age
male sex
smoking
family history
workers in industries exposed to carcinogens such as beta napthylamine, benzidine a rubber, textile/dye industry including hair dressers, printing and metal

Question 16

risk of smoking vs. risk of working in high risk industry

Answer 16

risk of working in high risk industries is negligible compared to increased risk with smoking.

Question 17

gold standard for diagnosis of bladder cancer

Answer 17

• flexible cystoscopy +/- biopsy for histology
• urine cytology - very specific but has low sensitivity (negative result cannot exclude cancer)

Question 18

pathological classification of transitional cell carcinoma

Answer 18

often multifocal
growth pattern may be papillary, sessile (flat), or carcinoma-in-situ (CIS)

Question 19

how do high grade tumours behave

Answer 19

more aggressively
faster growth and more likely to spread than lower grade tumours

Question 20

grading system for bladder cancer

Answer 20

grade 1: well differentiated
grade 2: moderately differentiated
grade 3: poorly differentiated

Question 21

TNM staging system

Answer 21

Question 22

how to diagnose carcinoma in situ

Answer 22

by biopsy/transurethral resection

Question 23

how to treat carcinoma in situ

Answer 23

intravesical immunotherapy - BCG (Bacillus Calmette-Guerin) with subsequent maintenance.
cystectomy if fails to respond to BCG

Question 24

why do you manage carcinoma situ of the bladder aggressively

Answer 24

high grade high risk form of urothelial cancer (unlike carcinoma in situ of other sites)
even when not showing invasion it is at high tsk of progression and should be aggressively managed

Question 25

how to treat carcinoma in situ of the bladder when BCG fails

Answer 25

cystectomy

Question 26

what is intravessical BCG

Answer 26

live attenuated bacillus calmette-guerin
instilled into the bladder and then drained away via catheter
performed weekly for 6 weeks and then mostly for one year
this is a form of immunotherapy and has been shown to decrease recurrence and progression of CIS and other high risk bladder cancers

Question 27

Ta and T1 bladder cancer define

Answer 27

Ta means the cancer is just in the innermost lining of the bladder
T1 means the cancer has begun growing into the connective tissue beneath the bladder lining

Question 28

treatment for Ta and T1 bladder cancer

Answer 28

TURBT (transurethral resection of bladder tumour)
Intravesical cytotoxics - using drugs such as mitomycin
intravesical immunotherapy - using drugs such as BCG (bacillus calmette-guerin)

Question 29

TURBT stands for

Answer 29

transurethral resection of bladder tumour

Question 30

how to treat muscle invasive bladder cancer

Answer 30

radical cystectomy
radiotherapy
combined treatments: chemotherapy followed by radical cystectomy or vice versa

Question 31

multi modal therapy

Answer 31

(when you combine chemotherapy/radiotherapy/surgery)
chemotherapy in addition to surgery - (either before surgery (neoadjuvant) or after surgery (adjuvant)) - is usually required.
if radiation is the prime modality, then cutting out as much of the tumour as possible via TURBT followed by concurrent chemo-radiation is the preferred approach

Question 32

cystectomy pre operative requirements

Answer 32

major surgery
requires thorough cardiovascular and respiratory system evaluation, bowel prep, blood cross-matched and stoma education pre-operatively

Question 33

cystectomy process

Answer 33

ileal segment is taken from the bowel and an end-to-end anastomosis is then performed to restore bowel continuity. (it’s mesentery is maintained)
this piece of bowel forms an ileal conduit and stoma.
both ureters are anastomosed to the piece of resected ileum to form the stoma.

Question 34

how to treat metastatic disease

Answer 34

systemic chemotherapy
palliative radiotherapy - to relieve symptoms and improve quality of life
palliative surgery - radical cystectomy and urinary diversion

Question 35

clinical presentation of renal cell carcinoma

Answer 35

often late presentation
triad of haematuria, flank pain and abdominal mass. usually asymptomatic
often detected as incidental finding during USS/CT abdo for other indications

Question 36

risk factors for renal cell carcinoma

Answer 36

smoking
family Hx
known kidney disorders requiring dialysis

Question 37

treatment for renal cell carcinoma

Answer 37

resistant to chemotherapy and radiotherapy
new drugs which target angiogenesis (eg. sutinib and sorafenib) are becoming available
treat with nephrectomy (partial or radical)

Question 38

neoadjuvant vs. adjuvant

Answer 38

neoadjuvant = before surgery
adjuvant = after surgery

Question 39

when should haematuria be investigated

Answer 39

it is a symptom of cancer and should always be investigated
in adults >50 bladder cancer is the most common cause

Question 40

what percentage of patients with frank haematuria who are investigated will be found to have urinary tract cancer

Answer 40

1/4
(25%)

Question 41

what should you do for patients with frank haematuria

Answer 41

refer to urologist for cytoscopy